Effects of remote, retroactive intercessory prayer on outcomes in patients with bloodstream infection: randomised controlled trial
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7327.1450 (Published 22 December 2001) Cite this as: BMJ 2001;323:1450
All rapid responses
Those correspondents who suggested that the controls
should be included in a cross-over study where they
become the treated sub-population in a subsequent
study have, I believe, misunderstood what is going on.
This study is not about reaching back from the future
into the past to change it but, instead, affecting the way
in which it occurred in the first instance, when these
clinical events were present tense.
Nor is this study a singular piece of benighted
research, as others seem to suggest. BMJ readers
may find the following URL of interest,
There they will find a number of papers addressing
various aspects of this subject, and I particularly draw
their attention to the work of physicist Helmut Schmidt.
Readers may also want to consider a just published
study carried out by researchers at Duke University’s
School of Medicine, which also deals with retroactive
Therapeutic Intent (TI). (1) (TI is, I think, a better term
than prayer, because the now considerable literature
on this subject suggests that any form of religious
belief, or none at all, seems capable of achieving the
effect.)
Using a well-designed randomized, controlled,
double-blind protocol, the Duke study involves prayers
from religious groups around the world for people
experiencing severe chest pains who are in danger of
imminent heart attacks. The treatment they received to
relief their crisis was cardiac catheterization and
angioplasty. As readers will know, the emergency
nature of these treatments means the procedures are
carried out immediately upon the patient being
admitted. That turns out to be the crucial aspect of the
retro-active aspect of this TI research, because
although the prayer groups were notified as soon as
possible after the patient was admitted, the initiation of
the actual TI sessions often began after the medical
treatment had already been completed. Both treated
and control groups received the same level of medical
intervention.
The TI practitioners had no contact with the patients,
and the health professionals administering the
treatments, and the patients themselves did not know
about the TI involvement. The outcome measure was
the number of complications each patient experienced,
with the comparison being made between the
subgroups. The TI recipients experienced, a 50 to 100
percent reduction in side-effects compared to the
controls.
Although this was just a pilot study with a patient
population too small to reach any definitive
conclusions, the results have proven so provocative
that researchers at more than half a dozen medical
centers in the U.S. have taken up this line of inquiry.
The study had another aspect that should be
mentioned. The TI practitioners were scattered all over
the world, including Nepal, India, Israel, and France, as
well as in the U.S., and their TI was expressed through
a wide range of religious traditions. No difference was
noted concerning one tradition being more powerful or
efficacious than any other.
Skeptics may find this line of inquiry philosophically
offensive but the gathering corpus of research
suggests that TI, whether retroactive or real-time has
the power to affect clinical outcome.
(1) Krucoff MW, Crater SW, Green CL, Maas AC,
Seskevich JE, Lane JD, Loeffler KA, Morris K, Bashore
TM, Koenig HG. Integrative noetic therapies as
adjuncts to percutaneous intervention during unstable
coronary syndromes: Monitoring and Actualization of
Noetic Training (MANTRA) feasibility pilot. American
Heart Journal. 2001;142(5):760-767.
-- Stephan A. Schwartz
Competing interests: No competing interests
Sir
-I read with interest the forementioned article that concluded with great
conviction that a prayer to sub group of patients with blood borne
infection led to a significantly better outcome in the interventional
group.
-I would like to know if this effect was dose dependant, and if the
relatives and general prayers for the sick that happen across the world
were banned from the control group during this period of "intervention".
-Whilst I am a firm believer in god and that patients and relatives gain
comfort through prayer, this study was fundamentally flawed. Furthermore I
have concerns that it could be used inappropriately by those wishing to
further their alternative medical practice by quoting this "conclusive
evidence" from your' well respected journal.
Competing interests: No competing interests
Applying the Talmudic method (which seems appropriate here), either
this study of Leibovici(1) shows God's intervention or it does not. If it
does not, then the experiment must be faulty. As Dace(2) points out, the
great principle of William of Ockham leads us to prefer this explanation
in science.
But suppose it does show God's intervention. The time-bending aspect
of this report is not of concern, as once the supernatural is invoked, the
sky's the limit (literally). If God can intervene to promote faster
recovery on request, then surely He can reach back in time to do so. But
consider the implication of accepting what Gardner(3) calls "the
superstition of the finger", that "God finds it necessary at intervals to
abrogate natural laws by injecting a finger into the universe to tinker
with it". Charles Darwin, for one, argued against this belief, concluding
that "there seems to me too much misery in the world" to believe that God
takes such a personal and protective interest in how we live our lives(4).
But the argument against the God of the finger becomes even stronger
if we accept Leibovici's experiment. We must only recall recent horrific
events--in Afghanistan, in the Balkans, in Israel, and in New York--to
realize that God is unwilling to lift his finger to prevent great
suffering and death among the innocent, and is unmoved by the many
impassioned prayers that he do so. Then why does he choose to respond when
called upon by perfunctory, impersonal prayer on behalf of long-ago events
involving far lesser suffering? The implication of Leibovici's conclusion
is that God may intervene, but He does so in a profoundly cruel,
capricious, and trivial manner. Those who believe in a just and loving God
should obtain little comfort from the outcome of this experiment. They
should pray that it is not true.
1 Leibovici, L. Effects of remote, retroactive intercessory prayer on
outcomes in patients with bloodstream infections: randomized controlled
trial. BMJ 2001; 323:1450-1451.
2 Dace, J. Occam's razor. Electronic response, BMJ 2001;323: 1450-
1451 at http://bmj.com/cgi/eletters/323/7327/1450#18236
3 Gardner, M. Phillip Johnson on intelligent design. In: Did Adam and
Eve Have Navels? New York: W.W. Norton, 2000, p. 22-23.
4 Milner, R. The first evolutionary psychologist. Scientific
American, Jan. 2002
[http://www.sciam.com/2002/0102issue/0102reviews1.html]
Competing interests: none
Competing interests: No competing interests
Editor– Leibovici should be congratulated for challenging us to
question our thinking about the nature of time and the potential
therapeutic effects of prayer.1 However, as with all scientific findings
we should view them within the context of the study's limitations. In
particular, can we be sure that the differences in outcomes between the
intervention and control groups were due to prayer rather than due to
differences in baseline characteristics? For example, were there
differences in the day of the week that patients in the two groups were
diagnosed or treated? This would be especially important if the control
group was more likely to have been investigated and treated on a weekend,
when arguably the level of care is inferior to the rest of the week. And,
since the patients were treated over a 7-year period, were there
differences in the distribution of the year of treatment for the two
groups? If there were, changes in the management of bloodstream infection
over time may have confounded the results. Also, Table 1 of the paper
shows that fewer patients in the intervention group acquired their
infection while in hospital. Although the difference was small (about 2%),
can we assume that it had no affect on outcome?
Professor Leibovici states that he had no competing interests.
However, competing interests include religious beliefs, which may have
affected the way this study was designed, analyzed or interpreted. Are we
to assume that Leibovici had no a priori beliefs about religion and
spirituality?
These potential biases, together with other methodological
limitations presented in the rapid response section of bmj.com, are not
reasons to question Leibovici's integrity nor should they distract us from
the originality of his study. However, they should serve to remind us that
scientific inquiry, for all its supposed rigour, can not provide a
definitive answer to every question. I thank Leibovici and the BMJ for
providing me with some (non-alcoholic) cerebral nourishment during the
festive period.
1. Leibovici L. Effects of remote, retroactive intercessory prayer on
outcomes in patients with bloodstream infection: randomised controlled
trial. BMJ 2001;323:1450–1.
Competing interests: No competing interests
Considering that 93% of leading scientists do not believe in
God [1], it is highly improbable that the poorly significant,
unimpressive results that Leibovici [2] ascribes to intercessory prayer
have to do with divine interventions. His unscientific paper simply
represents a cunningly disguised form of religious propaganda, which is
reminiscent of the so-called "scientific creationism" [3]: sheer religion
camouflaged with scientific terms to convince simpletons that the earth
was created by God, only about 6,000 years ago [3].
Leibovici's implicit message that God uses omnipotence to
comply with human prayers, instead of being comforting, is
both discouraging and worrying. It is already disquietingly absurd to
believe in a good and omnipotent God capable of creating the entire
universe but unable or unwilling to stop mere earthquakes, which, despite
having nothing to do with the "original sin", have painfully massacred
thousands of innocent babies during human history. It is even more
disquietingly absurd, however, to imply that God prefers to use
omnipotence to shorten, by a single day, the length of stay in hospital of
some patients "benefited" by intercessory prayer.
As someone stated most rightly, "religion is the rough equivalent of
firing an arrow at a blank target, then claiming
marksmanship by painting a bull's-eye around the point of
impact". Leibovici's grotesque paper [2] concurs to paint
that bull's-eye.
The fact that leading scientists overwhelmingly reject God [1] should
lead humankind to rely on reason, not on medieval superstitions. Reason and science unite people, whereas religions, being mutually
incompatible, generate and perpetuate divisions and wars.
Religions, as mere products of the
last 0.1% of human evolution, should be disregarded if they
are at odds with the biological ethics that have wisely guided humankind
for millions of years [4].
1. Larson EJ, Witham L. Leading scientists still reject God. Nature 1998;394:313.
2. Leibovici L. Effects of remote, retroactive intercessory
prayer on outcomes in patients with bloodstream
infection: randomised controlled trial. BMJ 2001;323:
1450-1.
3. Dalrymple GB. Radiometric dating and the age of the
earth: a reply to scientific creationism. Fed Proc 1983;
42:3033-8.
4. Baschetti R. Use of stem cells in creation of embryos.
Lancet 2001;358:2078.
Competing interests: No competing interests
Many previous correspondents have drawn attention to methodological,
ethical and epistemological difficulties attaching to this study. To the
former I would add just two - use of covariates, and publication bias. In
an RCT comparing, say, two blood pressure lowering agents, the usual
practice is to use the pre-randomisation baseline value of the parameter
as a covariate - the purpose not being to remove bias, which proper
randomisation does effectively, but to increase precision. In this study,
both of the "outcomes" on a continuous scale that are reported in table 2
- length of stay and duration of fever - were known, or determinable,
before the randomisation took place, just as were the data on gender, age,
source of infection etc. shown in table 1. Yet it would be inconvenient
to use each of these outcomes as a baseline covariate for itself, as the
difference in outcome between intervention and control groups would of
course then disappear. This illustrates that the validity of the standard
RCT methodology and interpretation becomes highly questionable once we
abandon the axiom that causality can only occur forwards in time.
Furthermore, the p-values reported for these two outcomes are at the
level that is conventionally regarded as "statistically significant",
though they are neither extreme nor independent of each other. Would the
study have been considered for publication, either by the author or the
journal, had statistically significant benefit not been attained?
(Indeed, what would have ensued had the study shown significant harm?) In
this instance, the reason one feels compelled to ask this seems to be
prior scepticism rather than sample size which appears to be adequate.
One correspondent has stated he has no conflict of interest. I feel
I must declare that I, and all of us, have a most serious personal
interest when it comes to the barely disguised further agenda of this
study, which many have already debated. The p-value attained in an RCT
represents extremely limited information bearing on this issue, compared
to the vast amount of information we have about the universe, even though
the former is experimental and the latter observational. If the issue
merely relates to the existence of a transcendent being that we can
manipulate within an RCT, there is little to be concerned about, as we are
then more powerful than this being. But - bearing in mind that this study
originated in Israel - if the one in question is the God whom the twelve
tribes of Israel worshipped, the God of Abraham, Isaac and Jacob, the one
presented in the Hebrew and Christian Scriptures as Almighty, we dare not
view the issue in a detached and disinterested manner. In these
Scriptures he is presented as the rewarder of those who diligently seek
him, but who is not mocked.
Competing interests: No competing interests
Only a randomized, controlled study can truly assess the effectivity
of an intervention such as intercessory prayer.Since the control group
received the best known medical treatment, the trial is ethical (except
perhaps the lack of informed consent). Therefore one cannot treat the
control group for methodological reasons. If we determine that
intercessory prayer is effective, the control group deserve the same
treatment, but giving them the treatment disqualifies the trial and
therefore there is no reason to give them the treatment.....
We are left caught in a bind (a direct result of research methodology)that
shows just how far from perfect our assessment and understanding of
reality really are ...
This may be what many scientists and physicians find most difficult to
accept.
The need for humility may be what this trial is meant to teach us.
Competing interests: No competing interests
It is understandably difficult to scientifically examine
interventions that are not easily quantified. However, like previous
authors studying the effects of prayer, Leibovici has presented an
incomplete description of methodology and inadequate examination of
confounding variables (1). In particular it is not known whether the
subjects in this study had previously been prayed for, and whether this
important confounding variable was also distributed in favour of the
intervention group. Consequently it seems more likely that the effect of
prayer was to produce a positive outcome for the study rather than a
favourable outcome for the intervention subjects. The retrospective
outcome measures were also unreliable: length of fever may be subject to
random interference from cooling measures and recording error, whilst
length of stay can be influenced by many factors other than a single
episode of sepsis. The discussion did not acknowledge these important
sources of bias.
However my main objection to the study is that it cannot be justified
on ethical grounds. Leibovici states that “we cannot assume a priori that
time is linear…or that God is limited by a linear time”. Therefore it was
argued that the intervention could be delivered in retrospect. However, no
matter how distant the separation of the illness and intervention, the
author was acting with the hope of influencing the outcome without the
informed consent of subjects (who had not even given permission for their
records to be examined for this purpose). No matter what the mode of
intervention and no matter how good the intention of investigators, it is
morally unacceptable to intervene experimentally in the routine care of a
patient without their permission. Ethical issues should also not be
limited by linear time.
Whilst it remains possible that such interventions produce benefits,
all investigators should be bound by the same rules of study design and
ethical integrity that apply to the global scientific community.
1. Leibovici L. Effects of remote, retroactive intercessory prayer on
outcomes in patients with bloodstream infection: randomised controlled
trial. BMJ 2001; 323: 22-29.
Competing interests: No competing interests
Was this paper by any chance supposed to have appeared at the
beginning of April?
Competing interests: No competing interests
Beyond Science?
It has been with interest that I have read this paper, the paper on
the Effect of rosary prayer and yoga mantras on autonomic cardiovascular
rhythms and all the associated rapid responses.
I think that perhaps a more appropriate title for the section would
have been: Before Science.
From the beginnings of recorded time up until the fairly recent past
(1700s and the advent of people such as Descartes), techniques such as
mantras and intercessory prayer have formed a substantial part of any
available healthcare service, and in many parts of the world are still
being used today.
Whether or not the science or ethics are sound in this research, we
should treat techniques such as prayer with respect. Rather than mocking
such research we should applaud those that are breaking "new" scientific
ground. Just because we ignore, are unaware, or do not understand it does
not mean that it cannot be possible. Just as, if a technique or procedure
is yet to have a clear scientific rationale does not mean that it is
invalid.
Many thanks for such stimulating topics of discussion.
Competing interests: No competing interests